Medical billing is a much more comprehensive process than just claim submission. Medical billing includes all activities assisting in revenue generation. Medical billing includes activities like benefits verification; coding; verifying patient demographics; claim submission; managing rejection; payment posting; account receivables management; denial management; provider enrollment and credentialing. Just submitting claims is not sufficient in medical billing, you have to make sure that you have submitted correct patient and insurance information; chosen correct procedure codes; used correct modifiers, and your documentation supports medical necessity. Improving your medical billing efficiency means improving all above-mentioned medical billing activities and team performance of billing, coding, and AR team.
Eligibility and Benefits Verification
You must have patient demographics and insurance information a few days prior to visit. Using this information, find out the patient’s insurance coverage for planned services and patient responsibility i.e., co-payment and deductibles. With coverage reports for all visits, your front desk team will be well prepared for patient questions and can collect co-payments and deductibles at the time of visit only. In case of non-coverage, you can contact patients prior visit and give them an idea about expenses. Maximum collection of patient payments is equally important as collection of insurance reimbursements.
Most solo providers or small practice owners tend to handle medical coding on their own. They continuously use the same procedure codes without an understanding of the consequences. Medical coding is a specialized branch of RCM and only specialty-wise trained medical coders should code for your practice. Most providers make severe coding mistakes like wrong use of time-based codes, unbundling, wrong use of modifiers, and many others. Such wrong use of procedure codes and modifiers may lead to payer audits for your practice.
Claim submission is a crucial part of medical billing, as timely submitted clean claims ensure quick insurance reimbursements. Your practice must have more than 95 percent of clean claim percentage to ensure all your billing activities are fitting into the right place. Claims will get rejected if you provide wrong patient demographics or insurance information or submit inaccurate billing information. To submit a clean claim, you must have correct data, knowledge of diagnosis codes, understating of billing guidelines, and payer reimbursement policies. If your claim gets rejected or denied then reworking them will lead to delayed payment and rework for billing and coding staff.
Rejections and Denials Management
When you receive a rejection, it means your might have provided the wrong patient and insurance information or you haven’t filled in critical claim information. Rejection means your claim has not reached the payer’s system and has been reverted by the clearinghouse. On the other hand denial means, your claim has been received and processed by the payer, and the payer has denied payment due to various reasons. When you receive an explanation of benefits (EOBs) you will receive a denial code/ remark code mentioning the reason for denied payment.
Most practice owners consider payment posting as non-important activity of medical billing. When you receive an explanation for benefits (EOBs) some claims might have been paid in full, some might have been denied and some claims might have been partial. Your billing team member should be well qualified and experienced to understand every line item in EOB and should further post-payment accordingly. Accurate payment posting will give you an idea about how much insurance has paid you, how much is the patient responsibility, and the total denied amount. You can plan your accounts receivable activities accordingly to recover maximum insurance and patient payments.
Account Receivables (AR) Management
When a claim is denied fully or partially by an insurance carrier, it goes to the Account Receivables (AR) team for further investment and rework. AR team will review such denied claims and will contact the insurance rep for resolutions. Common reasons could be non-coverage, failing to take prior authorizations, wrong use of modifiers, and incomplete documentation. Based upon resolutions received by the insurance rep, the AR team will rework the claim, provide additional information, remove wrong information, and will resubmit the claim. AR team will ensure that you will receive maximum insurance reimbursement on time.
Working on all the above-mentioned billing activities will help in improving your medical billing efficiency for your practice. If you don’t have billing, coding, and AR experts to handle these billing functions efficiently then think about outsourcing your medical billing. Medisys Data Solutions can assist you in medical billing, we will handle all billing activities on your behalf. Our expert team is well versed with coding guidelines and the latest billing updates. We ensure that you will receive accurate payment for services delivered. To know more about our billing services, contact us at firstname.lastname@example.org / 302-261-9187